Provider Demographics
NPI:1073998225
Name:ROSE, LANNY JR
Entity Type:Individual
Prefix:MR
First Name:LANNY
Middle Name:
Last Name:ROSE
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 412
Mailing Address - Street 2:
Mailing Address - City:BECKET
Mailing Address - State:MA
Mailing Address - Zip Code:01223-0412
Mailing Address - Country:US
Mailing Address - Phone:413-770-2928
Mailing Address - Fax:
Practice Address - Street 1:536 BROKER HILL ROAD
Practice Address - Street 2:
Practice Address - City:BECKET
Practice Address - State:MA
Practice Address - Zip Code:01223
Practice Address - Country:US
Practice Address - Phone:413-770-2928
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-29
Last Update Date:2015-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA9098363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant